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Sleep Surgeon Question 31

Question 31 - MMA and voice change, plus other related questions?

From: S.D.

Hello,

I am 35, moderately overweight (though not many would call me fat) and a singer and entertainer who relies on my voice (and to a much much smaller degree asthetics) who is seriously contemplating MMA for my UARS/OSA. Even when CPAP compliant I have little to no relief even at 20 cm/s. Dr Guilleminot at Stanford told me my airway is very small and my lower jaw is too small and needs advancement. My tongue literally is overflowing in my mouth and if I lean my head forward (as if sleeping on back relaxed) I can almost completely cut off airway. Actually I meeting with Dr. Li in a couple of weeks. Been suffering for about 2 years. It hit me HARD about a year and a half ago putting me out of work while doctors treated me for depression until finally a sleep study was ordered.

Also an extra note. Without CPAP in two sleep studies I was noted as having very severe OSA. With CPAP at Stanford I was noted in a third sleep study as having UARS. I thought this odd.

My questions are:

1. Can an MMA in any way degrade the voice (being a singer this is VERY important to me)? I think I read online one person having a problem after wards but since this occurs above the vocal chords I'm not sure how it could effect it.

2. Can the advancement be limited or keeping in mind esthetics and severity of the apnea? Also can the changes be modeled before being completed? I know nothing is 100%, but my apnea is moderate to severe but not quite to the point of a disability (yet). I've done some tests and it seems that my upper jaw would need an ever so slight advancement even with a 1cm advancement of lower to look "like my old self" more.

3. What long term studies of MMA surgeries have occurred?

4. Last question, is the GA more dangerous than the actually MMA surgery itself? I've read a lot about this surgery and airway is obviously key during this surgery since patients already have a small one. I imagine there is a certain amount of blood with the surgery as well that must be siphoned out ever so carefully. (sorry for graphicness)

ANYTHING is better than sleep apnea. If CPAP worked I would use it for sure. This is destroying my life. I've talked to one the best, now I will be talking to one of the best surgeons (much respect to Dr. Li in advance of meeting him/you).

thank you S.D.

Answer Provided by Dr. Kasey Li
April 2, 2008

MMA is performed above the vocal cords, thus it should not affect your singing. However, I always tell professional or serious singers that as sound travels from the vocal cords to the lips, it is affected by the soft tissues of the throat/mouth. The resonance can be different depending on the floppiness of the tissues. Sometimes a patients may have lots of floppy tissues and the voice may sound quite muffled. When the floppiness of the tissues are reduce by surgery, the voice actually becomes more clear and less muffled... Having said this, I would tell you that the likelihood of changing singing voice is very unlikely. However, singing requires lots of jaw movement with a good range of motion. The jaw range of motion is going to be limited for a few months after MMA, thus normal singing probably will not return for a few months.

When MMA is performed, esthetics is always taken into consideration. Since everyone looks different, the esthetic issues are also different. There are certainly ways to try to maximize the airway improvement and minimize esthetic compromise. I usually offer presurgical computerized projections regarding postsurgery esthetics if requested. However, it is not very accurate at all.

Finally, although genioglossus is often mentioned with MMA, I only performed simultaneous GA about 20% of the time. There are varying factors for me to decide to do the GA at the same time. My feelings are that GA is usually not necessary since MMA is already improving the airway to a maximum extent.

KKL